Presentation
Diffuse abdominal pain, peritoneal irritation.
Patient Data
Rectovaginal fistula, appearing to involve the posterior wall of the urinary bladder as well, as evidenced by a large amount of air in the bladder and the left ureter and a minute amount of air in the left renal collecting system.
The cause of the fistula is a calcified, coarsely serrated object 4.7 cm in length that traverses the left rectal wall, with its medial tip located in the fistula - calcified fecalith?
Right hydronephrotic sac. An apparent lobulation in its posterosuperior aspect has thinner walls and is suspicious for a small abscess. Markedly dilated right ureter with a thick wall, large stone in its pelvic part.
Left kidney is normal sized and shows good nephrographic effect. Tiny stone in the inferior calyx. The collecting system is mildly dilated.
Moderate amount of ascites. The free fluid in the hepatorenal fossa and that in the small pelvis have hyperdense edges - infected?
Fat stranding in the greater and lesser omenta.
Old fracture in the right femoral neck, with nonunion.
Other findings:
Dilated main pulmonary arteries. Mildly dilated ascending and descending thoracic aorta. Minute amount of right pleural effusion. Atrophic pancreas. Several diverticula in the descending and sigmoid colon.
In summary:
- Right hydroephrotic sac due to a large, longstanding ureteric stone. Suspected small perirenal abscess.
- Rectovagino-vesical fistula due to a long, serrated calcified process that crosses the rectal wall.
After a right nephrectomy and removal of most of the rectal foreign body in the same operation, a repeat CT was performed, where the urologist instilled diluted contrast material into the urinary bladder to prove a rectovesical fistula.
Penrose drain tied around the site of lateral rectal perforation, after removal of most of the offending calcified structure.
The foreign body turned out to be the patient's dentures, which she had swallowed several months earlier.
Case Discussion
The patient had swallowed her dentures several months earlier. The dentures passed the entire gastrointestinal tract, only to become lodged in the rectum. There, they eroded through its left wall into the mesorectal fat and created a fistula through its anterior wall into the vagina and posterior wall of the urinary bladder.
Concomitant right hydronephrotic sac with a small abscess, as stated in the pathology report.
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